663 Beauchamp Rd , _� .' � � �
` , DAVIE COUNTY HEALTH DEPARTMENT �
, Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-87G0
Account #: 990001044 Tax PIN/EH#: 5871-60-0361
Billed To: Dan Tullock Subdivision Info:
Reference Name: Dan Tullock Location/Address: Beauchamp Road-27006
Proposed Facility: Residence Property Size: 17.535 Acrs
ATC Number: 2368
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSiJED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). T'his Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: ,w'�!"yU�.aG(l��'�"� I' Date: ���,.��'�jJ�
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time.
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Environmental Health Specialist's Signature: Date: �(��gl�
DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT ���'��'-dd
• � �� , Environmental Health Section
` , P.O.Boz 848/210 Hospital Street
, Mocksville,NC 27028
(336)75]-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001044 Tax PIN/EH#: 5871-60-0361
Billed To: Dan Tullock Subdivision Info:
Reference Name: Dan Tullock Location/Address: Beauchamp Road-27006
Proposed Facility: Residence Property Size: 17.535 Acrs
**NO'i'�*'N'��iibgmprovem8ent/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with
Article 11 of G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
i
Residential Specification: Building Type #People� #Bedrooms � #Baths ,�Q,� '
Dishwasher: � Garbage Disposal: �� Washing Machine: � Basement w/Plumbing: � BasementJNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply-�* -�/ Design Wastewater Flow(GPD) �r� Site: New�Repair❑
/'
System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width���Rock Depth,7� Linear Ft.�
Other:
Required Site Modifications/Conditions:
INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6 "BELOW
FINISNED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis
system between 830 a.m.to 9:30 a.m.or 1:00 p.m.to 130 p.m. on the day of installation. Telephone#is(336)751-8760.****
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. Environmental Health Specialist's Signature: �'�'-iti� ,-t�� -�', '.� , Date: �"�'��''�1�
DCHD OS/99(Revised)
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. APPLICJ1T10N FOR SRE EVALUATION/IMPROVEMENT PERMIT&ATC ,�� 1
, Davie County Health Department t` 3 ^t��
Environmenta/Hea/th Section ✓ �
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 -
(336)751-8760
***I1�ORTANT*** THIS APPI,ICATION CANNOT HE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed �C'1 1`� � (,L � ��C /� Contact Person ��I�1E
Mailing Address �. (7_ �O �( �Y 7 6 Home Phone ��(p- 7 Sd R
City/State/ZIP C�em m o Ns, N C , .Z ,� � 1 Buainess Phone 9 9 g� S�� /
2. Name on Permi.t/ATC if Different tbax� Akievs
Mailinq lyddreas City/State/Zip
3. Application For: � Site Evaluation ,�Improvement Permit/ATC O�Both
a. syst� to se�,rice: � House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
s. �f Residence: � People �_ � Bedrooms _�_ # Bathrooms � '�1.
� Diahvasher � Gasbage Disposal � Washing Machine °�Basement/Plumbing , Basement/No Plumbing
6. If Susineas/Induatry/Other: SpaciPy type ii People # Sinka
Y Commodea � Shoxera $ Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per a$y�
7. Type of water supply: �❑ ounty/Cit ❑ W _r ❑ Comm t
I�UpU,� �Q re .t�✓ , :ua i S ru�i. j trP.�(�ho�c� ,'S Ue7�-�vA;�i�lb�,�
a. Do you anticipate additions or egpahsions of the facility this system is inten ed to serve? ❑Yes Q�No
If yes,w6at type?
***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN M T BESUBMITTED the client with THIS APPLICATION.
�,s.�J�i�c�P...�-
Property Dimensions: Scc R�e I�e c� �V e WRITE DIRECTIONS(from Mocksville)to PROPERTY:
TazOfficePIN: # J�$ �� � �PD- 03�� E�St' oN ( �g
PropertyAddress: RoadNamel�akcl,A�� Qo�d SOc�, oa ���'�%Moit ��Q
City/Zip �dU ANce , ��..�onG Le�.o a �Aac�nw,P/�d - Prr,�ae,. ;s
If in a Subdivision provide information,as follows: j tc S f ►�!or'F�, e� �i N�i�rrt �}rrh g
Name: Su6 0����s�o a ,
Section: Blcek: Lot: Date Property Flagged: �' �G-o D
This is to certify that the information provided is correct to the best of my knowledge. �un�'erstaud t�eaR aa�y��rmit(s)
issued hereafter are subject to suspensiou or revocation,if the site plans or intended use c6a�ge,or if�+h�entd���tion
submitted in this application is falsified or changed I,also,understand that I am responsible jor all charges incu�red Jrom
this application. I,hereby,give consent to t6e Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE mOlAfi�- I3� �-000 SIGNATURE A�v._I—
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
l��'Ac�1 mo�-�' � ' � S Sk r�c� O�/L�{P'( �i/'i�q� Date(s):
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Revised DCAD(07/99) Invoice No. � �^
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� .� , '; . DAVIE COUNT'Y�ALTH DEPARTMENT
� Environmental Health Section
, � Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001044 Tax PIN/EH#: 5871-60-0361
Bilted To: Dan Tullock Subdivision Info:
Reference Name: Dan Tullock Location/Address: Beauchamp Road-27006
Proposed Facility: Residence Property Size: 17.535 Acrs Date Evaluated: ��_������
Water Supply: On-Site Well_D/ Community Public
Evaluation By: Auger Boring f� Pit Cut �%
FACTORS 1 2 3 4 5 6 7
Landsca e osition � 4.
Slo e%
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH �- �
Texture rou ,
Consistence i i
Structure ,� ' �l
Mineralo , /
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON .
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
Texture
S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
Wet
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
Structure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogv
1:1,2:1,Mixed
Notes
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(unsuitable)
Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gaUday/ft2
DCHD OS/99(Revised)
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„ ' Health Departmen �� - �-r� �
�6r� � � ��ro� Health Section
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�' � �AR 2 3 2010 o P�tai Street , ��� �i '
p�,,��,.� ouri r# : 09-40-06
ENVIROP�MEtJTRL NEALTH Mocks lle, NC 27028 �
DAVIE COUNTY
Phoue:(336)-753-6780 Fax:(336)753-1G80
ON-SITE WAST�WATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
Name: ��r� 1�G L:L� 1 � "a c_,� Phone Number 3�`-���5' �a�'v (Home)
Mailing Address:—�\�;� ��c.in ' l�.c.�... R� `�S��, - ��G-�3 SS`► (�orlc)
�lc vc.�.c.� �v c. 2��v t� Ce i i
DetailedD'uectionsToSite: �vc•,-� �d�-,(.s�•�1�, �u �� � �=�5�- , JVi�1,.� c�.� �(� � � rc�t,�-
G r. �.����e s� � �'� �,�-�- �i .- '�'1 u c.�s ��w�-�.� �a �c,ln_�- o v. �e a�.��rti��Q
Properiy Address: (, (� ?v c�c,t,�c c1 w.P . c�v ct�-.c.r� � N C..� � �-G C� 1�,
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: ��L r� �cn v�;e.\ �t�-�l� �� Type Of Facility: ���c,`e �c1�:1�.,
Date System Installed(Month/Date/Year): Nu v � a Cl d � Number Of Bedrooms: 3 Number Of People: �
Is The Facility Currently Vacant? Yes No If Yes,For How Long?
Any Known Problems? Yes �N ' If Yes,Explain:
Please Fill In The Following Information About The NEW Facility: ,
Type Of Facility: S` in v�r'�o v4, Number Of Bedrooms: � Number of People �
Requested By: � �\L.��1 Date Requested: 3 1 a-3 1 \0
(Signature)
For Environmental Health Office Use Only
Approved Disapproved _ { � j
Comments: 3 _ O �l� � �'���1{�'\
y ; f �.� �.
. _-
Environmental Health Specialist Date: —�
*The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee
(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Check Money Order # Z Amount:$ /011•G(1 Date: �3-Z,3/d
Paid By: Received By: �
Account#: ,�5�.t8' Invoice#: Zz�/